Client Profile
- Mid-Western Multi Campus Facility
- Location: Mid-Michigan
- 500+ Physicians
- 600+ beds
- 20+ facilities/urgent care
Overview
The strategic partnership with a Mid-Western multi-campus medical facility was formed to solve the pressing issue of insurance underpayments and denials that were significantly impacting the facility’s financial performance. Recognizing the need for specialized support, they leaned on PMMC’s expert recovery team as an extension of their own operations.
Beginning in 2020 through today, PMMC’s recovery team utilizes its advanced software to meticulously identify and recover underpayments and denials previously undetected by the healthcare organization. This case study showcases the transformative impact of PMMC’s recovery services, emphasizing strategic approaches and tactics that drove measurable improvements.
The Challenge
The health system suffered significant financial challenges due to insurance underpayments and denials, particularly with Blue Cross Blue Shield (BCBS). These issues were not only affecting the facility’s bottom line but also placing substantial pressure on their internal billing staff. Traditional internal methods proved insufficient to address these persistent and intricate billing issues. After facing staffing concerns and not having enough team members to handle underpayments and denials, the health system turned to PMMC.
The Solution
To assist the facility, PMMC concentrated on addressing BCBS denials, underpayments, and billing issues.
- The Recovery Team identified high-cost drugs that were being billed incorrectly, resulting in incorrect reimbursements. By rebilling these claims, PMMC ensured the claims were reimbursed correctly.
- PMMC addressed, and is still addressing, a trend of BCBS underpayments, where observation services are being systematically denied.
- PMMC also discovered claims denied due to missing device codes. After adding the proper device codes, these claims were also reprocessed and paid correctly.
The Results
Utilizing advanced revenue recovery software and RecoveryAI®, PMMC helped ensure a consistent revenue stream with a three-prong approach:
- Focused Recovery on Known issues: PMMC’s targeted strategies effectively addressed BCBS denials and underpayments, significantly improving revenue recovery.
- Operational Efficiency Through Outsourced Expertise: PMMC’s expertise relieved the health system’s staff, allowing
them to focus on initial billing and payment, streamlined the billing process, and sped up rebilling with added regular discussions around insights, providing the client with the knowledge to succeed - Enhanced Financial Performance: PMMC’s collaboration led to the recovery of an additional $8.6M, demonstrating significant financial and operational improvements for the health system.
